APPLICATION FOR SERVICE RETIREMENT
1. Social Security Number
VIRGINIA RETIREMENT SYSTEM
P.O. Box 2500  Richmond, Virginia 23218-2500
Toll Free 1-888-VARETIR (827-3847)
Fax 804-786-9718
www.varetire.org
2. Check One
 Original Application
 Revised Application
Clear Form
PART A. MEMBER INFORMATION
3. Name
(First, Middle Initial, Last)
4. Address (Street, City, State and Zip+4)
5. Are you a Virginia resident?
6. Are you a U.S. citizen?
 Yes  No
 Yes  No
7.
Marital Status
 Never Married
8.
 Married or Separated
Home Phone Number
10. Birth Date (mm/dd/yy)
 Widowed
9.
 Divorced – Date of Divorce
(mm/dd/yyyy)
Daytime Phone Number
11. Retirement Date (mm/01/yy)
12. Do you intend to make a lump-sum purchase of service credit prior to retirement?
 Yes
 No
13. Will you be purchasing service credit with a sick leave payment? (Irrevocable option)
 Yes
 No
14. VSDP Participants Only: Will you be converting disability credit to service credit when
 Yes
 No
15. Will you be terminating all full-time employment with employers participating in VRS as
 Yes
 No
you retire? (Irrevocable option)
of your retirement date, including employment covered by an optional retirement plan?
(See instructions for more information)
16. Will you be terminating all part-time employment with the employer from which you are
retiring as of your retirement date? (See instructions for more information)
VRS-5 (Rev. 01/16)
 Yes  No  N/A
*VRS-000005*
17. SSN
PART B. PAYOUT OPTION SELECTION
18. Retirement Payout Options (Choose only one)
 Basic Benefit
 Survivor Option with
% payable to survivor
 Basic Benefit with a Partial Lump-Sum Option
Payment (PLOP)
 Survivor Option with
% payable to survivor,
and a Partial Lump-Sum Option Payment (PLOP)
 Advance Pension Option
19. Advance Pension Option If you chose this option above, 20. PLOP If you chose a payout option with a PLOP
enter the age at which you want your retirement benefit
to decrease:
payment above, choose the number of months for the
payment:
 12 months
 24 months
 36 months
21. If you chose a PLOP payment above, do you intend to roll the funds into an IRA or other qualified plan?
 Yes
 No
PART C. SURVIVOR INFORMATION
Complete Part C ONLY if you chose a Survivor Option in Part B. Your survivor is the person to whom your monthly
retirement benefit will continue upon your death. (This is different than naming a beneficiary, which you do on the VRS-2.)
22. Survivor’s Name
(First, Middle Initial, Last)
23. Relationship
 Spouse
24. Survivor’s Birth Date (mm/dd/yy)
 Other
25. Survivor’s SSN
26. Is your survivor a U.S. Citizen?
 Yes
 No
27. Survivor’s Gender
 Male
 Female
PART D. CERTIFICATION
28. Member Certification
I hereby certify: 1) All information I provide in this document is true and I understand that any willful falsification of facts presented
may result in prosecution as provided by law, 2) I have read and understand the service retirement information in the Handbook for
Members, 3) I will terminate all full-time positions with VRS employers prior to my retirement, and 4) I will not return to work in a
part-time position with my current employer following my retirement date for at least one full calendar month during which I would
normally work. Additionally, I agree that, in the event that VRS pays retirement benefits in excess of those to which I am entitled, I
or my estate will repay the excess to VRS. By signing this form, I hereby assign to VRS any VRS group life insurance benefits that
may be payable as a result of my death to secure repayment of any such retirement benefit overpayment.
Member Signature
Date
29. Spouse Certification (Required if married or separated)
I have read and understand the retirement payout options available under VRS. I am aware of and understand the retirement
payout option selected by my spouse in Part B and if my spouse chose a Survivor Option, the survivor benefits will be provided to
the person named in Part C. Further, I am aware that counseling regarding the payout options is available.
Spouse’s Signature
Address (If different from member’s address)
VRS-5 (Rev. 01/16)
Date
PART E. EMPLOYER CERTIFICATION
1.
Member Name
3.
Member covered under: (Check One)
 VRS  VRS Hybrid
4.
2.
 SPORS
Member Social Security Number
 JRS  VRS with Enhanced Benefits for Hazardous Duty Positions
VaLORS
If applicable, select job name for member who may be eligible for the state health insurance credit:
 Elected constitutional officer (Treasurer, Commissioner of Revenue, Clerk of Circuit Court, Commonwealth’s Attorney, Sheriff)
or an employee of an elected constitutional officer
 General registrar or employee of a general registrar
 Local social service board employee
5.
If applicable, select one for member covered by hazardous duty provisions:
 Sworn officer of a regional jail
 Disabled member in a non-hazardous position who retains benefits under the VRS with Enhanced Benefits
 Covered by the Hazardous Duty Alternate Option (VRS Plan 2 Firefighter, EMT or law enforcement officer with a political
subdivision which has elected to provide VRS Plan 1 age and service provisions)
 A uniformed officer in a hazardous duty position. This information is needed in order to comply with IRS
requirements regarding maximum benefits (IRC 415 limits).
Position held: ___________________________________
From:__________________
To: ________________
Full-time Classified
Part-time Classified
6.
Member Employment Status (State employees only)
7.
Last month the member’s creditable compensation will be reported to VRS (mm/yyyy):
8.
Last monthly creditable compensation amount to be reported to VRS for retirement:
NOTE: For educational employees, break down the amount to show the regular
monthly creditable compensation and any pay up.
(Monthly: $
+ Pay-up: $
= Total of $
9.
Last retirement contribution to be submitted (representing 5 percent of #8 above):
10. Last annual salary rate (reported for group life insurance purposes):
$
)
$
$
11. Date last annual salary rate became effective (mm/dd/yyyy):
12. Is the member currently on leave of absence without pay?
 Yes
 No
13. Start and end dates of contract for all positions (not limited to faculty positions):
Contract Start Date:
Contract End Date:
(mm/dd/yyyy)
14. Employer Name and Address (Please print or type)
(mm/dd/yyyy)
15. Employer Code
16. Authorization I certify: 1) the member will cease any non-covered part-time position with this employer prior to the retirement
date and will be fully removed from the payroll, 2) the member will not return to work in a part-time position with this employer
following the retirement date for at least one full calendar month during which the member would normally work and 3) there are
no prearrangements with the member to return to a part-time position.
______________________________________
Human Resources Signature
_______________
Date
______________________________________
Phone Number
______________________________________
Payroll Signature
______________
Date
______________________________________
Phone Number
17. Contact Information (Print the contact information for the person to whom VRS should direct questions regarding this application.)
Name
VRS-5 (Rev. 01/16)
E-mail Address
Phone Number
INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR SERVICE RETIREMENT
Please read the service retirement information in your Handbook for Members before completing your application.
You may obtain this handbook from your benefits administrator or view it on the VRS Web site (www.varetire.org).
Use myVRS on the VRS Web site to estimate your VRS benefits before applying for retirement.
Submit your application to the Virginia Retirement System (VRS) at least 60 days, but not more than four months,
prior to your effective date of retirement. This ensures you will receive your first benefit payment the first of the month
following your retirement date.
When submitting your application:
 Include a legible copy of your birth certificate. If your birth certificate does not include your full given name and
birth date, you must provide other legal documentation. Your application cannot be processed without this
document.
 Include a legible copy of your survivor’s birth certificate if you chose a survivor option. If your survivor’s birth
certificate does not include a full given name and birth date, provide other legal documentation.
 If you intend to purchase service credit with your sick leave payment or convert disability credit to service credit,
request your benefits administrator complete the necessary online certification. These options are irrevocable
and cannot be reversed.
 If you elect the Advance Pension Option, submit your estimate from the Social Security online benefit estimator
based on your Social Security earnings record using the instructions on the VRS website at
www.varetire.org/apo. This estimate must be less than 12 months old. It must be for the age at which you choose
for your VRS benefit to decrease and should assume no future earnings after leaving your covered position.
 Have your employer complete Part E if you are currently employed in a covered position or have been within the
last 12 months. If you are on VSDP long-term disability, send the application directly to VRS for certification.
 Complete and submit the Request for Income Tax Withholding (VRS-15) and the Authorization for Direct Deposit
of Monthly Benefit (VRS-57). Processing of your retirement application is delayed if the VRS-57 is not completed
and submitted with your application. Note: If you have fraud control or protection measures on the account that
will receive your VRS benefit payment, you may want to check with your financial institution before VRS sends
your first payment to be sure it is not rejected.
If all required documents are not received by VRS within 60 days of your anticipated retirement date, processing of
your application will be delayed. This will affect when your first benefit payment is made. VRS does not process
incomplete applications; your application is not considered complete until all documents are received. VRS will
process your application within 60 days of the date all documents are received.
Considerations:
You must terminate all full-time and part-time positions that are covered by VRS to receive a monthly retirement
benefit. This includes positions which provide retirement benefits in any VRS administered Optional Retirement Plan
or a public college or university Optional Retirement Plan authorized by the Code of Virginia. At the time of
retirement, you must also terminate work in any part-time positions not covered under VRS for the employer from
which you are retiring.
If you return to work in a full-time or part-time position covered by VRS for retirement purposes, a VRS-administered
Optional Retirement Plan or a public college or university Optional Retirement Plan authorized by the Code of
Virginia, your monthly retirement benefit must cease.
If you plan to return to work in a part-time position with any employer participating in VRS, your employer must
comply with Internal Revenue Service (IRS) rules about in-service distributions. For your employer to be in
compliance, you must:

Terminate all full- and part-time employment with your current employer before you receive your benefit payment.

Incur a break in service of at least one full calendar month before returning to part-time employment in a position
not covered by VRS with your current employer. This break must occur during a normal work period.
Note: State agencies are considered one employer. Retired state employees may return to work in part-time
positions with other state agencies after a full calendar month break in service during a normal work period.
VRS-5 (Rev. 01/16)
Member Responsibilities: Complete Parts A through D
Box 1-10:
Enter your personal information. In Box 2, check whether this is your original application or if you are
submitting a revised application.
Box 11:
Enter the date you plan to retire (the first of any month after your employment is terminated).
Box 12:
If you check yes, the purchase must be completed while actively employed and no later than your date
of termination. Your benefit cannot be calculated until payment for the purchase is submitted to VRS.
Box 13:
If you check yes, be sure your employer has completed the on-line certification for your accumulated
sick leave using myVRS Navigator.
Box 14:
If you check yes, be sure your employer has completed the on-line certification for your conversion of
disability credits using myVRS Navigator.
Box 15-16: You must terminate all full-time and part-time positions that are covered by VRS, including positions
covered by an optional retirement plan, to receive a monthly retirement benefit. At the time of
retirement, you must also terminate work in any part-time positions not covered under VRS for the
employer from which you are retiring. Choose yes or no as appropriate, or choose “N/A” in box 16 if you
have not been working in a part-time position and do not plan to do so prior to your date of retirement.
Box 18:
Choose only one payout option. Refer to your Handbook for Members to determine which option will
meet your retirement goal. If you are considering the PLOP, refer to the IRS 402(f) Special Tax Notice
on the VRS website to learn more about the tax implications of a lump-sum payment.
Box 19:
If you chose Advance Pension Option in Box 18, enter the age at which you want your temporarily
increased VRS benefit to be reduced. You must choose an age of at least 62 years, but no later than
your normal retirement age as defined by the Social Security Act. You must include an estimate from the
online Social Security Administration benefit estimator following the instructions on the VRS website at
www.varetire.org/apo. This estimate must be less than 12 months old, for the age at which you choose
for your VRS benefit to decrease and it should assume no future earnings after leaving your covered
position. Additional information about this option will be sent when your application is processed.
Box 20-21: Complete Box 20 only if you chose a payout option that includes a partial lump-sum payment. Indicate
the number of months on which the amount is to be based. For a 12-month payment, you must work at
least one year beyond the date you are first eligible for an unreduced retirement benefit; for a 24-month
payment, at least two years; and for a 36-month payment, at least three years. Complete Box 21 to let
VRS know if you intend to roll the PLOP payment into an Individual Retirement Account (IRA) or other
qualified plan. Additional information regarding your rollover options will be sent once your application for
retirement has been processed.
Box 22-27: Complete these boxes only if you choose a survivor option in Part B. If you choose a survivor option, you
must send a legible copy of your survivor’s birth certificate with this application.
Box 28:
Carefully read the certification statement. Sign and date the application. Your signature certifies that you
will repay benefits in excess of those to which you are entitled. It also certifies that you understand that
you cannot return to work in a part-time position working for the employer from which you retired without
first incurring the required break in service.
If you are unable to complete the application and you select a payout option other than the Basic Benefit
in Part B, an individual authorized to make testamentary changes on your behalf may complete your
application. Authorized individuals include: a court-appointed Guardian or Committee; an Attorney-inFact named in a Durable Power of Attorney; or an individual specifically authorized by a court order to
do so. A copy of the document providing such authorization must be presented to VRS for review before
the application can be processed. If the application is not signed and dated, it is not valid and a new one
must be completed. This may delay your first payment.
Box 29:
If you checked Married or Separated in Box 7, your spouse must sign and date the application on or
after the date you sign; otherwise, a new application must be completed. If you are unable to obtain your
spouse’s signature, contact VRS for additional information.
VRS-5 (Rev. 01/16)
Employer Responsibilities
Complete Part E. (To avoid processing delays, print or type your information and ensure all items are
completed.)
Box 4:
For members in a political subdivision, select the job name for the last position held if listed.
Members in these positions may be eligible for the state’s health insurance credit.
Box 5:
If the member is covered by hazardous duty provisions, check the applicable box.
Boxes 7-12: This information is used to project creditable compensation received up to the effective date of
retirement. If there is a change to this information, submit a Change to Certification (VRS-49) to
update the information on this form. Using myVRS Navigator, you must also correct any payroll
reported error that resulted from changes in these items or in the creditable compensation used to
calculate the average final compensation. To avoid an erroneous payment to the retiree, please
submit changes to VRS immediately.
After completing Part E:

Verify the application has been completed in its entirety, signed and dated as required.

If the member answered yes to the questions in Boxes 13 or 14 in Part A, ensure you have completed the
necessary on-line certification in myVRS Navigator before submitting the application.

Review the birth certificate (and the survivor’s birth certificate if applicable) to ensure it is legible.

Ensure the member has included an Authorization for Direct Deposit of Monthly Benefit (VRS-57) and a
Request for Income Tax Withholding (VRS-15).

If the member needs to apply for a health insurance credit, ensure the Request for Health Insurance Credit
(VRS-45) is completed and submitted with this application. If the member’s health insurance premium will
be paid through VRS payroll deduction, do not complete a VRS-45. If the member has additional health
insurance premiums to apply toward the credit, the VRS-45 must be completed and submitted with this
application.

For State Employees:


If an employee is retiring under the Workforce Transition Act of 1995, complete both pages of the
Employer Certification of Involuntary Separation under the Workforce Transition Act (VRS-11) and
submit it along with the VRS-5.

If an employee takes an immediate retirement and chooses to enroll in the State Retiree Health Benefit
Program, ensure the Health Enrollment/Waiver form is completed and submitted within 31 days of the
retirement date. (This form must be signed and returned to VRS even if the employee is waiving
coverage.)

If an employee has disability credits remaining under VSDP and wants to convert them to service credit,
ensure you have completed the on-line certification in myVRS Navigator before submitting the
application.
If an employee of a locality (not including constitutional officers or sheriffs) or school board is retiring under
the Transitional Benefits Program, complete both pages of the Employer Certification of Involuntary
Separation (VRS-11B) and submit it along with the VRS-5.
VRS-5 (Rev. 01/16)